case conferencec. serpiginous-like choroiditis multifocal choroiditis that progresses to a diffuse,...
TRANSCRIPT
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María José Capella, MD
February 18th, 2011
CASE CONFERENCE
martes 22 de febrero de 2011
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57-year-old woman
Decreased vision (central scotoma) OD 2 years ago
Had been stable till 2 months ago, when a new scotoma appeared
Had been on oral Prednisone and Acetazolamide in the past
PAST MEDICAL HISTORY:
• Hypertension
• Mild psoriasis
SOCIAL HISTORY:
• Travelled to Egypt 2 years ago
• Calcified nodule on the apex of her left lung (likely
childhood pleuritis?)
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57-year-old woman
Decreased vision (central scotoma) OD 2 years ago
Had been stable till 2 months ago, when a new scotoma appeared
BCVA: OD = 20/25 +2 J 1 (Metamorphopsia)
OS = 20/20 J 1
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57-year-old woman
Decreased vision (central scotoma) OD 2 years ago
Had been stable till 2 months ago, when a new scotoma appeared
BCVA: OD = 20/25 +2 J 1 (Metamorphopsia)
OS = 20/20 J 1
martes 22 de febrero de 2011
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VA = 20/25 +2
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0:34 1:47
3:10
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0:21 0:28
1:10 3:19
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0:21
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1:10
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3:19
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OD
OS
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DIFFERENTIAL DIAGNOSIS
?
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AMPPE
DIFFERENTIAL DIAGNOSIS
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AMPPE
MACULAR SERPIGINOUS CHOROIDITIS
DIFFERENTIAL DIAGNOSIS
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AMPPE
MACULAR SERPIGINOUS CHOROIDITIS
INFECTIOUS CHOROIDITIS
Tuberculosis / Syphilis / Toxoplasma
DIFFERENTIAL DIAGNOSIS
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TREATMENT
?
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Prednisone PO 60 mg/day
Tapering 10 mg/day every 10 days
TREATMENT
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- CRP +
- RF +
- HLA B27 –
- HSV 1 and 2: IgG +
- CMV / EBV -
- HCV / HBV / HIV –
- Syphilis –
- Toxoplasma: IgM - / IgG +
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- CRP +
- RF +
- HLA B27 –
- PPD > 20 mm
- HSV 1 and 2: IgG +
- CMV / EBV -
- HCV / HBV / HIV –
- Syphilis –
- Toxoplasma: IgM - / IgG +
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10 days
- CRP +
- RF +
- HLA B27 –
- PPD > 20 mm
- HSV 1 and 2: IgG +
- CMV / EBV -
- HCV / HBV / HIV –
- Syphilis –
- Toxoplasma: IgM - / IgG +
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10 days
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6 monthsVA = 20/20 -1
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8 monthsVA = 20/25
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8 monthsVA = 20/25
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8 monthsVA = 20/25
Is this a serpiginous choroiditis…?
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Autoimmune disease
Males = Females
30 – 60 years old
Bilateral, asymmetric
SERPIGINOUS CHOROIDITIS
CHRONIC AND RECURRENT INFLAMMATION
Beginning in the peripapillary region and spreading centrifugally
May rarely affect exclusively the macula: MACULAR SERPIGINOUS
CHOROIDITIS
Treatment: Corticosteroids + IMT
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8 monthsVA = 20/25
Is this a serpiginous choroiditis… or…
a TB serpiginous-like choroiditis…?
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Clinical disease caused by infection with Mycobacterium tuberculosis
1/3 of the world’s population are infected and 10% of these are likely to develop the
disease at some time in their lives
Primarily affects the lungs
Extrapulmonary involvement (GI tract, GU tract, CV system, skin, CNS and eyes) may
occur either in association or not with pulmonary tuberculosis
TUBERCULOSIS
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INTRAOCULAR TUBERCULOSIS
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis - an update. Surv Ophthalmol 2007
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A. CHOROIDAL TUBERCLES
Most common manifestation of tubercular
posterior uveitis
Small nodules, grayish white to yellow,
indistinct borders, mostly in the posterior
pole, ≤ 1/4 DD
Usually < 5 tubercles (there may be 50-60)
Most eyes do not develop anterior segment
or vitreous inflammation
POSTERIOR UVEITIS
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis - an update. Surv Ophthalmol 2007
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B. CHOROIDAL TUBERCULOMA
Large, solitary, subretinal mass (may mimic a tumor)
Yellowish, with surrounding exudative RD
4 - 14 mm
Hemorrhages and retinal folds may be seen on the tuberculoma surface
POSTERIOR UVEITIS
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis - an update. Surv Ophthalmol 2007
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POSTERIOR UVEITIS
C. SERPIGINOUS-LIKE CHOROIDITIS
Multifocal choroiditis that
progresses to a diffuse,
contiguous variety, acquiring an
active advancing edge like
serpiginous choroiditis
Diffuse plaque-like choroiditis
with amoeboidal spread
The 2nd eye may be affected months or years later
Relentless progression despite systemic corticosteroids and IMT
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis - an
update. Surv Ophthalmol 2007
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TB Serpiginous-like Choroiditis Classic Serpiginous Choroiditis
Inflammatory cells in the vitreous No concomitant vitritis
Posterior pole/periphery (usually sparing the peripapillary area) Peripapillary area spreading centrifugally
Asimetric Bilateral involvement more common
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A. Fluorescein Angiography
Active lesions: initial hypofluorescence with late hyperfluorescence
Healed lesions: transmission hyperfluorescence or blocked fluorescence due to
overlying pigment epithelial proliferation.
OCULAR IMAGING STUDIES
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B. Indocyanine Green Angiography
Active lesions: hypofluorescent spots during the early and late phases
The ICG changes are reversible and may be used to monitor response to therapy
OCULAR IMAGING STUDIES
Gupta V, Gupta A, Rao NA. Intraocular tuberculosis - an update. Surv Ophthalmol 2007
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CONFIRMED (DEFINITIVE) INTRAOCULAR TB:
1 clinical sign + 1 positive test of OCULAR investigations:
Demonstration of Acid-Fast Bacillus by microscope or culture of M.
tuberculosis from the ocular fluids
Positive PCR from ocular fluids
PRESUMED INTRAOCULAR TB:
1 clinical sign + 1 positive test of SYSTEMIC investigations:
Positive PPD / IGRA (QuantiFERON, T-SPOT.TB)
CXR: evidence of healed or active tubercular lesion
Confirmed active extrapulmonary tuberculosis (either by microscopic
examination or by culture)
OR a positive therapeutic test (positive response to 4-drug ATT x 4-6 wks)
+ exclusion of other uveitis entities (syphilis, toxoplasmosis, etc.)
GUIDELINES FOR DIAGNOSIS OF INTRAOCULAR TB
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CONFIRMED (DEFINITIVE) INTRAOCULAR TB:
1 clinical sign + 1 positive test of OCULAR investigations:
Demonstration of Acid-Fast Bacillus by microscope or culture of M.
tuberculosis from the ocular fluids
Positive PCR from ocular fluids
PRESUMED INTRAOCULAR TB:
1 clinical sign + 1 positive test of SYSTEMIC investigations:
Positive PPD / IGRA (QuantiFERON, T-SPOT.TB)
CXR: evidence of healed or active tubercular lesion
Confirmed active extrapulmonary tuberculosis (either by microscopic
examination or by culture)
OR a positive therapeutic test (positive response to 4-drug ATT x 4-6 wks)
+ exclusion of other uveitis entities (syphilis, toxoplasmosis, etc.)
GUIDELINES FOR DIAGNOSIS OF INTRAOCULAR TB
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CONFIRMED (DEFINITIVE) INTRAOCULAR TB:
1 clinical sign + 1 positive test of OCULAR investigations:
Demonstration of Acid-Fast Bacillus by microscope or culture of M.
tuberculosis from the ocular fluids
Positive PCR from ocular fluids
PRESUMED INTRAOCULAR TB:
1 clinical sign + 1 positive test of SYSTEMIC investigations:
Positive PPD / IGRA (QuantiFERON, T-SPOT.TB)
CXR: evidence of healed or active tubercular lesion
Confirmed active extrapulmonary tuberculosis (either by microscopic
examination or by culture)
OR a positive therapeutic test (positive response to 4-drug ATT x 4-6 wks)
+ exclusion of other uveitis entities (syphilis, toxoplasmosis, etc.)
GUIDELINES FOR DIAGNOSIS OF INTRAOCULAR TB
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PPD ++
PRESUMED INTRAOCULAR TB
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8 monthsVA = 20/25
T-SPOT.TB test: POSITIVE
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4 drugs ATT (isoniazid, rifampicin, pyrazinamide and ethambutol) for an
initial 2-month period followed by a choice of different options over next
4-7 months (total of 6-9 months)
ATT reduces the number of recurrences
Concomitant use of systemic corticosteroids (to combat delayed HS)
TREATMENT OF INTRAOCULAR TB
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8 monthsVA = 20/25
T-SPOT.TB test: POSITIVE
ATT with 3 drugs x 9 months
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7 months after starting ATTVA = 20/25 +2
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Excellent response
No progression of the CR lesions
No need for systemic steroids
7 months after starting ATTVA = 20/25 +2
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7 months after starting ATTVA = 20/20
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Infections must always be kept in mind
CONCLUSIONS
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Infections must always be kept in mind
Intraocular TB may present with features simulating SC
CONCLUSIONS
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Infections must always be kept in mind
Intraocular TB may present with features simulating SC
Tuberculous Serpiginous-like Choroiditis is a rare entity and may
occur without concomitant pulmonary involvement
CONCLUSIONS
martes 22 de febrero de 2011
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Infections must always be kept in mind
Intraocular TB may present with features simulating SC
Tuberculous Serpiginous-like Choroiditis is a rare entity and may
occur without concomitant pulmonary involvement
Establishing a diagnosis of intraocular TB remains challenging
(most are diagnosed as presumed rather than definitive
intraocular TB)
CONCLUSIONS
martes 22 de febrero de 2011
![Page 51: CASE CONFERENCEC. SERPIGINOUS-LIKE CHOROIDITIS Multifocal choroiditis that progresses to a diffuse, contiguous variety, acquiring an active advancing edge like serpiginous choroiditis](https://reader033.vdocuments.mx/reader033/viewer/2022041816/5e5b372b9e7ecf0253207c41/html5/thumbnails/51.jpg)
Infections must always be kept in mind
Intraocular TB may present with features simulating SC
Tuberculous Serpiginous-like Choroiditis is a rare entity and may
occur without concomitant pulmonary involvement
Establishing a diagnosis of intraocular TB remains challenging
(most are diagnosed as presumed rather than definitive
intraocular TB)
Distinguishing it from SC is critical because the treatment is
completely different (immunosuppressive drugs vs ATT)
CONCLUSIONS
martes 22 de febrero de 2011
![Page 52: CASE CONFERENCEC. SERPIGINOUS-LIKE CHOROIDITIS Multifocal choroiditis that progresses to a diffuse, contiguous variety, acquiring an active advancing edge like serpiginous choroiditis](https://reader033.vdocuments.mx/reader033/viewer/2022041816/5e5b372b9e7ecf0253207c41/html5/thumbnails/52.jpg)
martes 22 de febrero de 2011
![Page 53: CASE CONFERENCEC. SERPIGINOUS-LIKE CHOROIDITIS Multifocal choroiditis that progresses to a diffuse, contiguous variety, acquiring an active advancing edge like serpiginous choroiditis](https://reader033.vdocuments.mx/reader033/viewer/2022041816/5e5b372b9e7ecf0253207c41/html5/thumbnails/53.jpg)
Thank you
martes 22 de febrero de 2011